The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on policy review, medical record review and staff interviews, the facility failed to perform a face-to-face assessment by a licensed independent practitioner within 1 hour after the initiation of a restraint intervention in 1 of 2 patients (Patient #6) requiring restraint interventions.

The findings include:

Review of facility policy "Seclusion/Restraint", last review date: 05/09/2017, revealed, "... PROCEDURE... A Qualified RN (Registered Nurse) (QRN) conducts an in-person, face-to-face assessment of the patient in S/R (Seclusion/Restraint) within 1 hour of initiation and documents findings on the One Hour Face-to-Face evaluation. The purpose of this evaluation by the Licensed Independent Practitioner (LIP) or QRN is to determine if the use of these measures is justified to prevent the patient from causing harm to self or others. It is also completed to ensure that the use of S/R poses no undue risk to the patient's medical or psychological well-being..."

Medical record review revealed Patient #6 was a [AGE] year old female, admitted to the facility for treatment of "threats towards others and herself" and "plans to stab/hang herself." Review revealed she required an S/R intervention on 06/18/2017 at 1429. Review of a "PHYSICAL INTERVENTION - ONE HOUR FACE-TO-FACE EVALUATION" document written by RN #1 revealed, "Initiation of Intervention date & (and) time: 618 (June 18, 2017) 1429... Face-to-face evaluation date & time: 6/18/17 1830 (4 hours and 1 minute after the initiation of the S/R intervention)... Describe behaviors and/or events leading up to seclusion/restraint: pt kicking, hitting staff, cursing, yelling, out of control, uncooperative... REVIEW OF Symptoms Circulatory Status WNL (Within Normal Limits)... Pulses present in all extremities: Yes... Respiratory Status WNL... Skin Assessment Intact... Nutrition/Hydration Fluids are being offered every 15 minutes... Skin turgor: Good... Pain/Discomfort: Denied..." Review of a "PHYSICAL INTERVENTION - HOURLY FLOW SHEET" revealed, "Date: 6/18/17 TYPE OF INTERVENTION Physical restraint Time in: 1429 Time out: 1434... Seclusion Time in: 1434 Time out: 1604 (1 hour and 35 minutes after the initiation of the S/R intervention)... Time: 1604 BP (Blood Pressure) HR (Heart Rate) RESP (Respirations) TEMP (Temperature) [all declined] Pain/Injury... No... Nutrition & hydration denies... Circulation & ROM (Range of Motion) pt walking, talking, agreeable to seclusion ending... Hygiene & elimination denies need... Staff intervention talking to staff, understanding... Staff signature: (RN #1's signature)..." Review revealed Patient #6 was continuously monitored by a Mental Health Worker during the S/R intervention episode.

Staff interview was conducted on 06/28/2017 at 0950 with RN #1, who recalled Patient #6, and was her assigned RN during the S/R intervention on 06/18/2017. Interview revealed the required one hour face-to-face assessment by a QRN was not performed within one hour of the initiation of the S/R episode. Interview revealed this S/R intervention was her (RN #1's) first S/R intervention since being employed at the facility. Interview revealed RN #1 had received education and training on S/R interventions upon hire, which included training that a 1 hour face-to-face assessment by a licensed practitioner after the initiation of an S/R intervention was required. Interview revealed hospital policy was not followed.

Staff interview with the Director of Nursing (DON) was conducted on 06/28/2017 at 1008, which revealed facility policy was not followed. Interview revealed if an S/R intervention was initiated on 06/18/2017 at 1429, a 1 hour face-to-face assessment by a licensed practitioner would have been expected to be completed by 1529.

Based on policy and procedure review, medical records review, patient complaint form review, staff interviews, phone interviews, and review of NC TRACKS Provider Portal (multi-payer Medicaid Management Information System for the North Carolina Department of Health and Human Services) the facility failed to provide required prior approval form as requested by patient's pharmacy to ensure a patient was able to receive discharge medications for 1 of 2 discharge records (Patient #5).

The findings include:

Review on 06/27/2017 revealed a policy titled "Discharge Planning/Discharge Process" last revised 04/03/2017 revealed "...D. The PA (Physician Assistant), FNP (Family Nurse Practitioner), or other healthcare provider will ensure that the physician is aware of the medical needs of the patient as well as the medication recommended by that provider to ensure continuity of care......The physician will review the discharge plan to determine if there are any factors that may affect continuing care needs of the patient, including a review of recommended medications......The RN (Registered Nurse) working with the physician and the assigned clinical staff member, will ensure completion of the Discharge/Aftercare Plan. The summary includes transportation mode, aftercare referrals and a list of medication with physician prescription..."

Review of the medical record on 06/27/2017 of Patient #5 revealed a [AGE] year old male admitted on [DATE] for major depressive disorder. Patient #5 was discharged to home and picked up by his mother on 05/19/2017. Review of the "Patient Demographic Profile" revealed Patient #5 had "Medicaid Eastpointe" as his primary insurance and "self pay after insurance" for his secondary insurance. Review of "Discharge Medication Reconciliation" dated 05/19/2017 and signed by Patient #5's mother revealed Patient #5 was given a paper prescription for Trileptal (anti-seizure medication) 300 mg, Zyprexa Zydis (anti-psychotic medication) 10 mg, and Cogentin (medication used to treat side effects of anti-psychotics)1 mg. Continued review revealed a box checked yes for "Was the patient provided medication education?" Further review revealed FNP #1 wrote Patient #5's prescriptions.

Interview on 06/27/2017 at 1530 with DRM (Director of Risk Management) revealed faxes received from community pharmacies for prior approval of medications happened frequently. Continued interview revealed "sometimes the faxes come across the main fax machine." Further interview revealed if the DRM saw a prior approval fax she would give it to the appropriate provider assistant. Continued interview revealed no one monitored faxes for prior approval frequently.

Interview on 06/28/2017 at 0940 with NM (Nurse Manager) revealed phone calls from community pharmacies for prior approval request of medication do not all go to the same employee. Continued interview revealed sometimes community pharmacy calls were transferred to medical records or the house supervisor. Whomever the phone call was transferred to would let the provider assistant know who then informed the provider. Further interview revealed this process was not documented in the patient's chart because the patient was discharged when these phone calls occurred.

Interview on 06/28/2017 at 1035 with DCS (Director of Clinical Services) revealed at discharge patients or patient's guardian were not asked what pharmacy they were going to use "because patients were given paper prescriptions."

Interview on 06/28/2017 at 1100 with FNP #1 revealed in order for patients to get prior approval for antipsychotic medication the provider had to approve the medication in NC TRACKS. Continued interview revealed all patients on Medicaid need prior approval for antipsychotic medication. Continued interview revealed that prior approval for medications was done automatically by the provider in NC TRACKS on the day of discharge. Continued interview revealed the pharmacy that the patient went to would be able to look at the prior approval form electronically in NC TRACKS and the patient would be able to obtain their antipsychotic medication.

Phone interview on 06/28/2017 at 1325 with DON (Director of Nursing) to NC TRACKS call center revealed Patient #5's prior approval form for Zyprexa on NC TRACKS was approved on 06/02/2017 (14 days after discharge).

NC 373
NC 786
NC 170